1. Beal, Judy DNSc, RN
  2. Bauer, Jill A. MA, RN
  3. Diedrick, Lee A. MA, RN, C-NIC

Article Content


With more than 1.4 million women of child-bearing age in the United States regularly using illicit drugs (Fraser, Barnes, Biggs, & Kain, 2007), the number of newborns exposed to substance abuse before birth has increased dramatically (Vasquez, Pitts, & Mejia, 2008) and healthcare providers are often forced to make difficult infant-care decisions. Among the continuum of crucial decisions, healthcare providers must determine whether these newborns should stay in the mother's care following hospital discharge or be placed in a foster-home environment. It is my belief that these babies are best served physically, developmentally, and psychologically when they remain with their mother.


For some of these infants, staying with their mother may mean being in a potentially riskier home environment. It is known that common comorbidities of substance abusers can include psychopathology, depression, antisocial personality, and family violence (Fraser et al., 2007). However, maintaining a strong mother/infant dyad can have value that precludes these risks and can ultimately benefit both mother and baby in the long term (Abrahams, Kelly, Payne, Thiessen, Mackintosh, & Janssen, 2007; Fraser et al., 2007).


When appropriately supported in the hospital and following discharge, both Fraser et al. (2007) and Abrahams et al. (2007) found that substance-abusing mothers kept close to their infant following birth and developed skills to improve their own situation as well as that of their baby's. With resources to provide education, support, and mentoring, the mothers improved attachment and bonding, care-giving behaviors, and developed a stronger ability to recognize and respond to their baby's behavioral cues (including symptoms of neonatal abstinence syndrome). Separation, in contrast, contributed to decreasing maternal attachment with the baby, increased relapse of maternal chemical abuse, and ultimately increased incidence of neonatal abandonment and/or loss of custody (Abrahams et al., 2007).


Abrahams et al. (2007) also found that avoiding separation, particularly in the crucial first 4-6 weeks of life, promoted a strengthened mother/infant bond that resulted in fewer withdrawal symptoms and required fewer treatment interventions for the newborn. These infants also had a shorter length of hospital stay and experienced more effective mothering, which seemed to ease the newborn's transition to extrauterine life. Establishing successful breastfeeding additionally reduced their withdrawal and need for treatment.


Individuals opposing my view may emphasize the increased risk to the infant associated with the comorbidities of substance abuse; particularly after discharge. Admittedly, I agree that without proper connection to resources, supportive care, and follow up, these infants may have increased risk of harm. According to Vasquez et al. (2008), evaluation of the home environment is crucial to assuring safety as well as improving the developmental, cognitive, and psychosocial outcomes of these infants in the first 2 years. However, it is well-documented that all parents of high-risk infants need additional supportive care (Vasquez et al., 2008), and I believe that healthcare providers must devote no less attention to the needs of these high-risk patients.


As healthcare professionals working in the clinic, hospital, home, and community, nurses are in a valuable position to offer the needed guidance, education, support, assessments, and interventions for these families through the continuum of care. Nurses can help to increase the mother's self-esteem and skills of parenting, support her chemical abuse treatment, promote resources that improve her social/economic/physical circumstances, and ultimately increase her ability to love and care for her infant. Advocating for the infant, the nurse can identify healthcare needs after discharge, assess overall well-being and development of the infant, and help to assure that best outcomes are achieved in the infant's early years.



Abrahams R. R., Kelly S. A., Payne S., Thiessen P. N., Mackintosh J., Janssen P. A. (2007). Rooming-in compared with standard care for newborns of mothers using methadone or heroin. Canadian Family Physician, 53(10), 1722-1730. [Context Link]


Fraser J. A., Barnes M., Biggs H. C., Kain V. J. (2007). Caring, chaos and the vulnerable family: Experiences in caring for newborns of drug-dependent parents. International Journal of Nursing Studies, 44(8), 1363-1370. doi:10.1016/j.ijnurstu.2006.06.004. [Context Link]


Vasquez E. P., Pitts K., Mejia N. E. (2008). A model program: Neonatal nurse practitioners providing community health care for high-risk infants. Neonatal Network, 27(3), 163-169-0832. doi:10.1891/0730-0832.27.3.163 [Context Link]



Care of infants diagnosed with neonatal abstinence syndrome (NAS) has become a critical issue throughout the United States. Maternal opioid usage and subsequently, infants diagnosed with NAS, quadrupled between the years 2000 and 2009 (Patrick, Schumacher, Benneyworth, Krans, McAllister, & Davis, 2012). The increased volume of babies with NAS has added significant pressure on healthcare professionals and governmental services to provide effective discharge planning and home care for affected infants and their families. Healthcare professionals must decide if the infant should be discharged to home with the mother or be placed in foster care. Based on current research status, high-risk maternal behaviors, and abstinence syndrome symptoms, it is my opinion that outcomes of infants diagnosed with NAS are improved when the infant is discharged to foster care.


Research studies have demonstrated inconclusive results whether care at home by the mother or by foster care provides the best outcomes for NAS infants. The validity of study data is hampered by a multitude of issues. These issues include small sample sizes, assessment at a variety of postbirthing ages, and the use of diverse evaluation tools. A major issue with the results of prenatal substance use studies is that very few have exclusively examined opioid exposure. NAS symptoms are caused by withdrawal from maternal opioid use, and studies of infants exposed to other substances do not reflect how the NAS symptoms of high-pitched cry, irritability, poor sleep, and feeding behaviors have an impact on the home environment (Irner, 2012).


Of the handful of research studies focused on prenatal opioid exposure a few studies have implicated opioid exposure and NAS as a negative impact on development, behavior, and cognitive functioning. Research studies of long-term outcomes of NAS-diagnosed infants have identified the infant's environment to be as influential as the opiate exposure, with lower socioeconomic status a noted risk factor for poor cognitive outcomes. Conversely, an enriched environment has been shown to compensate for the impact of prenatal opioid exposure (Irner, 2012).


Based on the literature to date, it has been suggested that opioid-dependent mothers are often engaged in a life-style that puts their infants at risk of developmental delay. Opioid-dependent mothers tend to be poly-drug users, move frequently, and have a lower socioeconomic status. The home environment of substance-abusing women is also more likely to include exposure to chronic stress and violence, poor nutrition, and inadequate social support (Minnes, Lang, & Singer, 2011). All of these factors could have significant negative implications for the well-being of the baby. It does not make sense to place a vulnerable infant who suffers from withdrawal into a fragile home environment. Parental follow through on medication administration, nonpharmacological NAS symptom management, and healthy parenting behaviors is an unreasonable expectation.


Costs are high for the long-term hospitalization needed for the NAS infants to reach appropriate medical stability for discharge to a less-than-ideal environment. In their review, Minnes et al. (2011) cited several studies, which evaluated the impact of extensive home support for prenatal substance-exposed infants discharged to home. Three years of biweekly home visits demonstrated marginal benefits. It would be more cost-effective to have an established, trusted cadre of foster care providers who are well-trained in the needs of NAS. Foster care providers can provide the stable environment and expertise that makes earlier discharge possible for the infants with NAS during this critical time of stress. It is my opinion that the developmental, behavioral, and cognitive outcomes of infants are improved when the infant is placed in well-designed foster care, until research data provide more evidence on the impact of home environment on infants with NAS.



Irner T. B. (2012). Substance exposure in utero and developmental consequences in adolescence: A systematic review. Child Neuropsychology, 18(6), 521-549. [Context Link]


Minnes S., Lang A., Singer L. (2011). Prenatal tobacco, marijuana, stimulant, and opiate exposure: Outcomes and practice implications. Addiction Science and Clinical Practice, 6(1), 57-70. [Context Link]


Patrick S. W., Schumacher R. E., Benneyworth B. D., Krans E. E., McAllister J. M., Davis M. M. (2012). Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. Journal of the American Medical Association, 307(18), 1934-1940. doi:10.1001/jama.2012.3951. [Context Link]